What Are Effective Psychological Or Multi-Modal Interventions for Adults Experiencing Chronic

What are effective psychological or multi-modal interventions for adults experiencing chronic pain?

Evidence Compass

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Technical Report

What emerging interventions are effective for the treatment of adults with PTSD?
A Rapid Evidence Assessment
August 2013

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What are effective psychological or multi-modal interventions for adults experiencing chronic pain?

Disclaimer

The material in this report, including selection of articles, summaries, and interpretations is the responsibility of the Australian Centre for Posttraumatic Mental Health, and does not necessarily reflect the views of the Australian Government. The Australian Centre for Posttraumatic Mental Health (ACPMH) does not endorse any particular approach presented here. Evidence predating the year 2004 was not considered in this review. Readers are advised to consider new evidence arising post publication of this review. It is recommended the reader source not only the papers described here, but other sources of information if they are interested in this area. Other sources of information, including non-peer reviewed literature or information on websites, were not included in this review.

© Commonwealth of Australia 2014
This work is copyright. Apart from any use as permitted under the Copyright Act 1968, no part may be reproduced by any process without prior written permission from the Commonwealth. Requests and inquiries concerning reproduction and rights should be addressed to the publications section Department of Veterans’ Affairs or emailed to .

Please forward any comments or queries about this report to

Acknowledgements

This project was funded by the Department of Veterans Affairs (DVA). We acknowledge the valuable guidance and enthusiastic contribution of our steering committee for this project, which comprised senior personnel from various government departments and the scientific community.

We acknowledge the work of staff members from the Australian Centre for Posttraumatic Mental Health who were responsible for conducting this project and preparing this report. These individuals include: Associate Professor Meaghan O’Donnell, Dr Lisa Dell, Dr Naomi Ralph, Dr Tracey Varker and Dr Olivia Metcalf.

For citation:

Australian Centre for Posttraumatic Mental Health (2013). What emerging interventions are effective for the treatment of adults with PTSD? A Rapid Evidence Assessment. Report prepared for the Department of Veterans Affairs. Australian Centre for Posttraumatic Mental Health: Authors.

Table of contents

Acknowledgements

Executive Summary

Introduction

Mindfulness

Acceptance and Commitment Therapy (ACT)

Meditation and Transcendental Meditation

Power Therapies

Traditional Acupuncture

Experiential psychotherapies

Method

Defining the research question

Search strategy

Search terms

Paper selection

Information management

Evaluation of the evidence

Ranking the evidence

Results

Summary of the evidence

Acceptance and Commitment Therapy

Traditional Acupuncture

Adventure therapy/ Outward Bound therapy, Art therapy, Canine therapy and Equine therapy

Meditation

Transcendental Meditation

Mindfulness

Music therapy

Emotional Freedom Therapy/Technique

Rewind Therapy/Technique, Thought Field Therapy, Traumatic Incident Reduction

Visual Kinaesthetic Dissociation Technique

Discussion

Implications

Limitations of the rapid evidence assessment

Conclusion

References

Appendix 1

PICO

Appendix 2

Information retrieval/management

Appendix 3

Screening Form

Appendix 4

Quality and bias checklist

Appendix 5

Evidence Profile

Appendix 6

Evaluation of the evidence

Executive Summary

• While efficacious psychological interventions for post-traumatic stress disorder (PTSD) have been established, a number of new therapies termed ‘emerging interventions’ have generated interest within the popular media. This has created a flow-on effect whereby trauma survivors, including veterans, are increasingly requesting access to emerging interventions. Therefore, the efficacy of these interventions needs to be established.
• The aim of this rapid evidence assessment (REA) was to review the effectiveness of emerging interventions for the treatment of adults with a diagnosis of PTSD. The emerging interventions identified for review included mindfulness, acceptance and commitment therapy, meditation, transcendental meditation, acupuncture, power therapies (including emotional freedom technique (EFT), thought field therapy (TFT), visual-kinaesthetic dissociation (VKD), rewind technique (RT) and traumatic incident reduction (TIR) and experiential psychotherapies including adventure therapy, art therapy, music therapy, canine and equine assisted psychotherapy.
• Literature searches were conducted to collect studies published from 2003-2013 that investigated emerging interventions in adults with a diagnosis of acute stress disorder or PTSD. Studies were excluded if they did not measure PTSD symptoms, less than 70% of participants met diagnostic criteria for PTSD or where the sample was receiving concurrent psychological treatment for PTSD. Studies were assessed for quality of methodology, risk of bias, and quantity of evidence, and the consistency, generalisability and applicability of the findings to the population of interest. These assessments were then collated for each emerging intervention to determine an overall ranking of level of evidence support for each intervention.
• The ranking categories were ‘Supported’ –clear, consistent evidence of beneficial effect; ‘Promising’ – evidence suggestive of beneficial effect but further research required; ‘Unknown’ – insufficient evidence of beneficial effect; ‘Not supported’ – Clear, consistent evidence of no effect or negative/harmful effect.
• Eight studies met the inclusion criteria for review. Two-thirds originated from the USA, a quarter came from the UK and a final study originated from Uganda.
• One study investigated acceptance and commitment therapy, one investigated acupuncture, one study investigated meditation, two studies investigated transcendental meditation, one study investigated music therapy, one study investigated EFT and final study investigated VKD. Overall, the quality of the studies was low and had high risk of bias. This influenced the ranking of the studies significantly.
• The evidence for traditional acupuncture in treating PTSD in adults received a ‘Promising’ ranking.
• The evidence for acceptance and commitment therapy in treating PTSD in adults received an ‘Unknown’ ranking. Other interventions that received an ‘Unknown’ ranking were meditation, transcendental meditation, music therapy, EFT, and VKD.
• No studies met the inclusion criteria for a number of the emerging interventions, including canine and equine assisted psychotherapy, adventure therapy, mindfulness, TFT, RT, TIR, and art therapy. The lack of any studies for these interventions meant they did not achieve a ranking according to this REA methodology.
• Well conducted, rigorous trials are required to test the efficacy of interventions identified in this REA in the treatment of PTSD. Currently, there is a paucity of evidence supporting to use of these interventions in the treatment of PTSD.

Introduction

Guidelines for the treatment of acute stress disorder (ASD) and posttraumatic stress disorder (PTSD)1-3outline the range of psychotherapeutic interventions effective for the treatment of adults with PTSD. These evidence-based interventions include trauma-focused cognitive behavioural therapy (TF-CBT) and eye-movement desensitisation and reprocessing therapy (EMDR)1, underpinned by a strong evidence base supporting their use across a variety settings and populations. At the same time, there are a large number of therapies in the treatment of adults with ASD and PTSD that can be classed as ‘emerging interventions’, but their effectiveness to improve symptoms has not yet been firmly established in the scientific literature.

The aim of the current review was to examine the scientific literature for evidence of support for a number of therapies considered to be emerging interventions for the treatment of adults with PTSD. Three broad categories of emerging interventions for the treatment of adults with PTSD were considered. These included psychological interventions (e.g., mindfulness and power therapies), physical therapies (traditional acupuncture), and a range of experiential psychotherapies including adventure therapy, art therapy, music therapy, or animal therapy (i.e. canine therapy, equine therapy). A brief description of these therapies is provided below.

Mindfulness

Mindfulness-based therapies are considered part of the ‘third-wave’ of cognitive and behavioural psychotherapies. Although relatively new to Western approaches, mindfulness has a long history of practice in Eastern philosophies (e.g., Buddhism, Taoism and Yoga). Mindfulness can be defined as ‘the awareness thatemerges through paying attention on purpose, in the presentmoment, and nonjudgmentally to the unfolding of experience moment by moment’ (p.145) andincludes ‘an affectionate, compassionate quality within the attending, a sense of openhearted, friendly presence andinterest’ (p.145)4. It is from this stance - that is at the same time highly present, yet removed from the event and overwhelming emotions - that the individual is able to approach difficult internal experiences, and reconsider these as transitory ones inherent to our humanness. In comparison to standard treatments like CBT, the individual’s symptoms are not the focus of treatment. Rather, the treatment is focussed on helping the individual redirect attention to the present moment, and reconsider relationships between thoughts, feelings and current experience5.

Acceptance and Commitment Therapy (ACT)

ACT is an increasingly popular form of mindfulness-based therapy and was considered separately in this review, in addition to mindfulness more broadly. ACT encourages the individual to create a rich and meaningful life, through committing to taking effective value based actions, remaining fully present and engaged, and accepting difficult experiences as an inevitable part of life6. To achieve this, ACT promotes the six core processes of: acceptance, cognitive defusion, being in the present moment, self as context, values, and committed action7.In common with mindfulness, ACT does not focus on inner experiences - but instead targets the effects of these experiences on behaviour, using behavioural based approaches that promote actions consistent with the individuals values8. In this way, ACT is thought to alleviate mental distress and symptoms of disorder more as a by-product, than an actual focus of the therapy6.

Meditation and Transcendental Meditation

Meditation is well-known and has been practised as a part of western approaches to psychotherapy for many years. Broadly speaking, meditation involves developing a greater awareness of the mind. There are a range of types of practises and disciplines within the meditation field, that are distinguished by their distinct aims9. Mantra meditation, for example, involves focussing on an object to bring about a sense of peace and relaxation9. Mantram repetition is the selection of a meaningful word or phrase with spiritual associations to focus attention on through silently repeating it, which has been found to have a calming effect in stressful situations10.In the current review, meditation and transcendental meditation were considered. Transcendental meditation (TM) also involves mantra repetition, but the aim is to bring about a transcendental experience through the repetition, a step beyond the heightened awareness of mantram repetition. TM is a formalised practise, and begins with the individual sittingcomfortably with their eyes closed, and silently appreciating a mantra at ‘finer’ levels until the mantra becomes increasingly secondary to the persons experience and ultimately disappears as self-awareness becomes more primary (the experience of transcending)11.

Power Therapies

‘Power therapies’ is a collective term used to refer to a number of novel and supposedly fast acting exposure-based treatments specifically for PTSD. The current review examined the evidence base for support for the use of the following techniques in the treatment of adults with PTSD; emotional freedom technique (EFT), thought field therapy (TFT), visual-kinaesthetic dissociation (VKD), rewind technique (RT) and traumatic incident reduction (TIR). Common to all power therapies is some form of visualisation regarding the traumatic event/s. Some of the therapies pair the visualisation with physical touch, or working with physiological responsiveness. For example, EFT requires the individual to focus on the traumatic memory while the therapist (or patient) taps lightly on various traditional acupuncture meridian points on the face, upper body and hands12. Underlying EFT is the assumption that emotional disturbances associated with traumatic events are caused by disturbances in the body's energy field (meridian system)12.

By comparison, VKD does not use physical touch, and involves the therapist working with the individual’s physiological responsiveness. In VKD the individual briefly focusses on the traumatic event/s until there is an observable physiological response (change in heart rate, breathing, or skin tone) detected by the therapist13,14. The individual’s attention is then brought back to the present context. This is followed by a three-part dissociation (a series of visualisations) with the individual, for example, asked to imagine they are seated in a movie theatre watching themselves, watching their trauma story on the screen; to view their story in black and white; and later very quickly in reverse. After this series of visualisations, each sensory system is probed for possible triggers using the questions that evoked the physiological response at the beginning. When there is no physiological response, the intervention is thought to have worked13. VKD is argued to assist individuals to have a degree of kinaesthetic detachment from kinaesthetic memories of the traumatic event/s.

The process for RT and TIR also begin with the individual being asked to close their eyes and watch a ‘movie’ of their trauma. However, the next step in RT involves the individual stepping in to the movie at the end, and imaging it is been quickly rewound so that it is not possible to see or feel the same amount of content as in the forward playing movie. When this is done, the individual opens their eyes, signalling the end of the therapy15. It is argued that RT provides a strategy for intrusion phenomena by providing a metaphorical ‘box with a key’ into which the trauma content can be stored and locked. In the TIR technique, after the individual has watched the ‘movie’ of their trauma, they are asked to disclose what was seen and experienced to the therapist16. These two steps are repeated (often in the one session) until an end point is reached, where all memories of the event/s have been recalled and no longer cause distress16. It is hypothesised that TIR allows the individual to experience the trauma related content in a way that is briefly separated from the cognitive processing that takes place during the recall and verbalisation of the experience17, enabling processing of the content until extinguishment.

It is acknowledged that there are similarities between the power therapies and other types of imaginal exposure therapies which are a standard feature of trauma-focussed CBT. Yet the power therapies remain novel in that the client is not generally required to verbalise or otherwise express their experience, but rather to re-experience it in their mind just as it regularly re-represents itself to them15.

Traditional Acupuncture

Acupuncture is a modality of Traditional Chinese Medicine practiced in Asia for thousands of years, that has continued to gain acceptance for the treatment of physical and mental health issues in the mainstream health systems of Western countries18,19. Traditional Chinese Medicine views the health and well-being of an individual holistically, and acupuncture is one of several techniques used to treat the ‘underlying disharmony’ contributing to illness18. In practical terms, acupuncture is a procedure where small, solid needles are placed into rationally chosen points in subcutaneous tissue for a given period of time and manipulated (by turning the needle at the appropriate time)20. This process gives a sensation of ‘de qi’ (a fullness or heaviness and warmth, but not pain) and aims to move vital energy around the body to restore balance between bodily systems18. Acupuncture stimulates neural pathways, including central, peripheral and autonomic nervous systems and the limbic system, as well as immune and inflammatory system responses.

Experiential psychotherapies

Another group of emerging interventions for the treatment of adults with ASD and PTSD are loosely grouped together as experiential psychotherapies because they draw on certain modalities of lived experiences for therapeutic gain. Adventure therapy (such as the Outward Bound program21), art therapy, music therapy, and canine and equine assisted psychotherapy were examined in this review.

Adventure therapy is a term used to cover a broad range of wilderness, outdoor and adventure based interventions22. The Outward Bound Experience (OBE) is well known for its use with veterans and employs a series of challenging experiences in a wilderness setting to facilitate change21. Over the intervening years, wilderness, outdoor and adventure-based interventions has held appeal for the treatment of the complex problems at risk youth present. However, concern over the lack of engagement of families systems in this process, and the need for the industry as a whole to establish standards of care, accreditation and credentialing of practitioners has been noted23-27.

The literature on the use of animal based psychotherapies – in particular equine and canine therapy have also focussed on work with at risk adolescents, as well as people with trauma histories, substance use disorders and veterans28,29. At the core of these approaches is therapeutic alliance between the individual, the horse or dog, and the therapist30,31. The animal provides a means for working through interpersonal and emotional issues that traditional client/ therapist paradigms is not able to provide30,32,33. Issues of trust, agency and responsibility, self-worth and self-esteem are commonly worked on in this form of psychotherapy.

Art therapy is a form of exposure therapy, and provides a visual means for the expression of trauma content (without verbalising) that is possibly aligned with the visual manner in whichtrauma content presents itself to the individual34,35. Art therapy is argued to assist individuals to recall, re-enact, and integrate the trauma content with their sense of self which may assist the individual to have a sense of mastery of emotion36. Art therapy is also hypothesised to allow for the containment of the trauma experience in the art object which may assist the individual to regain a sense of control over past and present experiences35,36.

Music therapy is argued to work on trauma symptoms at a preconscious level, with neural areas common to both the trauma experience and music stimulated through the sensory experience37. The emotional responses that are elicited are then able to be worked with providing self-expression and a sense of control over past and present experience38. In some forms of music therapy for trauma, the therapist will work with the individual on composing and recording relaxing music, before leading in to musical improvisation and song-writing to provide a cohesive narrative of their trauma and autobiographical experiences39. In the group music therapy format, individuals might be introduced to a range of instruments and encouraged to improvise, while the therapist provides accompaniment and gradually extends and varies the nature of the musical interaction. This is followed by reflection, with the therapist providing supportive psychotherapeutic interventions, drawing together common themes38. In addition to the therapeutic process, music therapy is hypothesised to assist with relaxation and thus have an impact of the modulation of arousal40.